Opioid versus non-opioid postoperative pain management in otolaryngology.

BACKGROUND: The opioid epidemic in the United States has had devastating consequences, with many opioid-related deaths and a significant economic toll. Opioids have a significant role in postoperative pain management. Here we aim to analyze differences in postoperative opioid and non-opioid pain medications regimens following common otolaryngological surgeries between two large tertiary care medical centers: the Milton S. Hershey Medical Center, USA (HMC) and The Chaim Sheba Medical center, Israel (SMC). METHODS: A retrospective chart review of patients undergoing common otolaryngological procedures during the years 2017-2019 was conducted at two tertiary care centers, one in the U.S. and the other in Israel. Types and doses of postoperative pain medications ordered and administered during admission were analyzed. Average doses ordered and administered in 24 h were calculated. Opioid medications were converted to a standardized unit of morphine milliequivalents (MME). Chi-square test and Wilcoxon rank-sum test were used to compare the groups. RESULTS: The study included 204 patients (103 U.S., 101 Israel). Patient demographics were similar except for a longer length of stay in Israel (p < 0.01). In the U.S., 95% of patients were ordered opioids compared to 70% in Israel (P < 0.01). In the U.S., 68.9% of patients ordered opioids received the medications compared to 29.7% in Israel. The median opioid dose ordered in the U.S. was 45MME/24 h compared to 30MME/24 h in Israel (P < 0.01), while median dose received in the U.S. was 15MME/24 h compared to 3.8MME/24 h in Israel (P < 0.01). Opioid prescriptions at discharge were given to 92% of patients in the U.S. compared to 4% of patients in Israel (p < 0.01). A significantly higher number of patients in the U.S. were prescribed acetaminophen and ibuprofen (p < 0.0001). Dipyrone was prescribed to 78% of patients in Israel. CONCLUSIONS: HMC demonstrated a significantly more permissive approach to both prescribing and consuming opioid medications for postoperative pain management than SMC for similar, common otolaryngological surgeries. Non-opioid alternatives and examining the cultural and medical practice-based differences contributing to the opioid epidemic should be discussed and reevaluated.

Assessing the Different Oncologic Disease Distribution and Postoperative Complications of Octogenarian and Nonagenarian Head and Neck Oncology Patients.

PURPOSE: The admission rate of patients aged 80 years or older (oldest-old) with head and neck (HN) oncologic disease is on the rise. Our goal was to study the demographic characteristics, reasons for admission, types of surgical procedures, and postoperative complications of the oldest-old patients with HN malignancy. MATERIALS AND METHODS: We conducted a retrospective cohort study including all inpatients aged 80 years or older who were admitted to the department of otolaryngology-head and neck surgery or department of oral and maxillofacial surgery because of HN oncologic disease between 2009 and 2013. The control group was composed of a matched number of randomly selected patients aged 60 to 79 years. We compared the demographic characteristics, diagnoses, comorbidities, surgical interventions, and postoperative complications of the 2 age groups to characterize the oldest-old patients' admissions and determine whether age alone increases the risk of postoperative complications. RESULTS: The study included 109 oldest-old patients (median age, 83 years) and 107 patients in the control group (median age, 68 years). Although the oldest-old patients had significantly more underlying diseases (4.41 vs 2.86) and drugs prescribed (4.76 vs 3.21), similar rates of postoperative complications occurred in both groups. An important finding was that ischemic heart disease and chronic lung disease were the only significant risk factors for postoperative complications among the oldest-old patients (odds ratio on multivariate analysis of 5.5 and 4.5, respectively). CONCLUSIONS: Although comorbidities and prescribed drugs are more prevalent in the oldest-old patients, the rate of postoperative complications did not differ between the age groups, suggesting that age alone should not be a factor in the surgical treatment of HN malignancies.

Warthin tumor within the superficial lobe of the parotid gland: a suggested criterion for diagnosis.

The location of Warthin tumor (WT) in the parotid gland impacts the surgical approach and may be indicative of the elusive origin of this intriguing entity. Location in the deep versus superficial lobe of the gland is not directly addressed when defining WT characteristics. Our observation, of rare occurrence of deep lobe WT, if at all, led to the current investigation. The study design is cohort study. This is a retrospective chart review of all patients undergoing parotidectomy for WT in two tertiary academic referral centers: the Sheba Medical Center (SMC), Israel, and the Christiana Care (CC), Newark, Delaware, USA. 122 consecutive adult patients underwent parotidectomy for WT (72 from SMC and 50 from CC). Seventy percent were males, with a mean age of 60.6 years. Bilateral WT or multi-centric WT were found in 9.8 and 17.2% of the cases, respectively. In one case, the tumor was described as originating in the deep lobe. In all other cases, the tumor originated and was limited to the superficial lobe. 99.2% of WT originated in the superficial lobe, corresponding with the few reports directly addressing its location in the gland. The reason for the tumor to be limited almost uniformly to the superficial lobe is unknown, and could be related to the etiopathogenesis of this elusive entity. We suggest adding tumor location within the superficial lobe to the common characteristics of WT (male, smoking, and lower pole) that serve as "common criterion" while evaluating a parotid lesion.

Prognostic Factors in Differentiated Thyroid Cancer Revisited.

BACKGROUND: More than 90% of all thyroid cancers are differentiated thyroid carcinomas (DTC) with a 10 year survival rate greater than 90%. The commonly used risk stratification systems for DTC include: European Organization for Research and Treatment of Cancer (EORTC), AGES (Age, histologic Grade, Extent of tumor, Size), AMES (Metastasis) and MACIS (Completeness of resection, local Invasion). Other systems are also utilized. Several new factors that may be involved in DTC risk stratification have emerged in recent studies, with other "traditional" factors being challenged. OBJECTIVES: To present recent updates in the literature on new potential prognostic factors for DTC. METHODS: We conducted a literature review and analysis of publications regarding DTC prognostic factors or risk stratification published in the last 10 years. RESULTS: Several new factors with potential prognostic implications for DTC were noted, including family history, lymph node involvement parameters, positive PET-CT findings, multifocal disease, thyroglobulin level and several molecular markers including BRAF. Increasing age is associated with poorer outcome in DTC; however, recent studies suggest that the cutoff point of 45 years may be contested. Furthermore, several studies have shown contradictory results regarding male gender as a negative prognostic factor, thus questioning its prognostic significance. CONCLUSIONS: A number of new factors with potential prognostic implications for DTC have emerged and should be addressed. However, their role and possible inclusion in new staging systems has yet to be determined.

Use of the vessel sealing system in tracheostomy.

BACKGROUND: Tracheostomy is a frequent, and at times semiurgent, surgical procedure. It is performed in close proximity to the thyroid gland, and in many cases requires division of its isthmus, putting a patient in danger of significant bleeding. OBJECTIVES: To examine prospectively the feasibility of vessel sealing in tracheostomy. METHODS: A vessel-seating device was used in 24 consecutive patients undergoing tracheostomy. There were no exclusion criteria for enrolling the patients. No other hemostatic technique was used for dividing the isthmus. RESULTS: There were no bleeding events throughout the postoperative period. The operating time saving was 5-10 minutes. CONCLUSIONS: Use of the vessel sealer was found to be straightforward, efficacious, rapid and safe.

Tumor-host histopathologic variables, stromal myofibroblasts and risk score, are significantly associated with recurrent disease in tongue cancer.

Margin status, a major prognostic parameter in oral cancer, was analyzed vis-à-vis the histopathologic parameters of risk scores and stromal myofibroblasts. Specimens of tongue carcinoma (n = 50) were submitted to a risk score assignment consisting of the worst pattern of invasion, lymphocytic infiltration, and perineural invasion. Frequency of stromal myofibroblasts (alpha-smooth muscle actin stain) was assessed. A triple immunostaining assay with E-cadherin, Ki-67 and alpha-smooth muscle actin was used to identify carcinoma cells undergoing epithelial-mesenchymal transition. Margins were considered 'clean' if the tumor was >or=5 mm away from them. Patients

Parotid mass as presenting symptom of lymphoma.

BACKGROUND: Lymphomas arising from the parotid gland are an uncommon entity, said to account for only 0.6-5% of tumors or tumor-like lesions of the parotid, and are therefore commonly overlooked. This misdiagnosis often leads to unnecessary diagnostic procedures, delaying the initiation of proper treatment. OBJECTIVES: To examine the clinical, diagnostic, therapeutic and survival data of patients with this disease. METHODS: We retrospectively reviewed our experience with patients diagnosed and treated for parotid lymphoma in our medical center during the period 1998-2008. RESULTS: The 13 patients in the series were aged 42-83. Twelve had non-Hodgkin's lymphoma and 1 had Hodgkin's lymphoma. In eight, parotid mass was the first manifestation of the disease, while in five who were in clinical remission its reoccurrence was first manifested in the parotid gland. Mean survival was 6.3 years CONCLUSIONS: Since parotid lymphoma is uncommon, it is often overlooked in the differential diagnosis. Methods of diagnosing and treating parotid lymphoma are different from those of other parotid pathologies. A high index of suspicion is warranted in order to provide a quick and efficient diagnosis and treatment without subjecting the patient to unnecessary tests and procedures.

Outcome of tracheostomy in patients over 85 years old (oldest-old patients).

OBJECTIVE: To investigate morbidity, complication rate, and mortality in oldest-old patients who undergo tracheostomy. STUDY DESIGN: Historical cohort study. SUBJECT AND METHODS: The medical records for 64 patients (>85 years) who underwent standard or percutaneous tracheostomy between 2001 and 2005 in a tertiary care hospital were reviewed for in-hospital and out-of-hospital mortality, complications, and decannulation rate. RESULTS: Twenty-eight (43.8%) patients were discharged from the hospital and all remained tracheotomized at that time. Postoperative mortality had not been related to the procedure itself and the mortality rate reached 75 percent within the first three postoperative months and 93.8 percent within the first year post-tracheostomy. The post-tracheostomy course was complicated in three (4.7%) patients. There was no significant correlation between the length of hospital stay or survival and demographic parameters, pneumonia as the reason for mechanical ventilation, or performance of surgery before tracheostomy. CONCLUSION: Tracheostomy is a safe surgical procedure in the oldest-old patients. The high rate of the postoperative mortality is not related to the procedure itself. The possibility of permanent stoma should be considered and discussed with the patients and their families during the preoperative counseling.

A prospective study of surgical margin status in oral squamous cell carcinoma: a preliminary report.

A protocol was created for prospective margin status evaluation of patients with Oral SCC. Margins are evaluated intra- and post-operatively during three stages. Patients were divided into three groups: group 1 in which one margins were sampled randomly, group 2 with frozen sections taken from the surgical bed and 3 in which they were taken from the tumor specimen itself. Patients in group 3 showed the best correlation with final margin status and survival.

Recurrent pleomorphic adenoma: is treatment considerably delayed thus affecting surgical morbidity?

OBJECTIVE: To examine the incidence of late presentation of patients with recurrent pleomorphic adenoma (RPA) of the parotid gland. METHODS: This is a retrospective analysis of patients treated in our center. We examined patients demographics, disease characteristics, treatment, and outcome and as well as the time period length from the first discovery of a recurrent mass until seeking treatment at our clinic and its effect on morbidity. RESULTS: A total of 30 patients were included. 26% underwent initial enucleation in other institutions. In eight patients (26%), the recurrence of the mass was second or higher. The patients average time period length until seeking treatment was 2.48 years, with 33% of patients showing a time period length of over three years. Multifocal tumor, tumor diameter larger than 2 cm and facial nerve involvement were found in 15 (50%),16 (53.3%) and seven (25%) patients respectively. Patient's delay of presentation by ≥3 years was associated with a tumor size of ≥2 cm (Relative Risk [RR] = 2, p = .02). Patient's delay of presentation by ≥2 years was also associated with a trend towards a higher rate of post-operative facial nerve palsy (RR = 3.37, p = .07, CI = 0.88-12.85). CONCLUSION: Most patients with RPA were presented late, thus affecting disease extent and surgical morbidity.

Prognostic value of lymph node ratio in head and neck squamous cell carcinoma.

BACKGROUND: Lymph node ratio (LNR) is increasingly reported as a potential prognostic tool. The purpose of this review was to analyze the available literature on the prognostic significance of LNR in head and neck squamous cell carcinoma (HNSCC). METHODS: A PubMed internet search was performed and articles meeting selection criteria were reviewed. RESULTS: Twenty-eight studies were identified in the literature dealing with the prognostic value of LNR. The published results are variable with a range of cutoff values of LNR associated with prognosis (overall survival [OS] and/or disease-specific survival [DSS]) between 0.02 and 0.20, with an average of 0.09. CONCLUSION: The LNR is reported to be of value in assessing prognosis in the patients with HNSCC. Although it is easy to calculate and could be considered in the staging of these patients, the currently available evidence in the literature does not yet provide a solid base for implementation.

A phase II study of Imatinib for advanced adenoid cystic carcinoma of head and neck salivary glands.

Adenoid cystic carcinoma of the salivary glands is characterized by a poor response to chemotherapy. Most cases of adenoid cystic carcinoma express the c-kit protein. Imatinib mesylate (Gleevec) inhibits several protein-tyrosine kinases, including c-kit. We therefore hypothesized that Imatinib may be an effective drug in patients with locally advanced or metastatic adenoid cystic carcinoma and conducted a phase 2 trial in order to study this. Patients with locally advanced or metastatic adenoid cystic carcinoma and c-kit positive tumours were eligible. Fourteen patients were screened and 10 patients (71%) with c-kit positive tumours entered the study. Treatment was begun at a dose of Imatinib of 400mg/day. Dose escalation was allowed in the absence of toxicity. The dose was increased to 600mg/d in three patients and 800mg/d in one patient. Three patients required dose reduction to 300mg/d, due to grade 3 toxicity. No grade 4 toxicity was seen. No objective responses were seen. Two patients (20%) exhibited stable disease for 11 and 14 months, respectively. All other patients stopped treatment after 2-14 (median 6) months due to progressive disease. Imatinib has no major effect on advanced adenoid cystic carcinoma of the head and neck.

The clinical behavior of isolated sphenoid sinusitis.

OBJECTIVE: We sought to study the clinical behavior and treatment outcome of isolated sphenoid sinusitis (ISS). STUDY DESIGN AND SETTING: We conducted a retrospective study of patients diagnosed with ISS in a tertiary medical center over 20 years. RESULTS: Of 72 patients with ISS, 79 percent had acute symptoms, 15 percent had chronic symptoms, and 6 percent had incidental radiological findings. Fifteen percent were children. Most patients were diagnosed between January and April (P < 0.01), and increasing incidence was noted over the years (P < 0.001). Headache was the most common presenting symptom (85%). Chronic patients complained also of nasal symptoms (82%). Six patients had a major complication of sinusitis (none of them were children), and two patients died. Immunocompromised patients had more major complications (P

Posterior glottic stenosis in adults.

BACKGROUND: Posterior glottic stenosis is a complication of prolonged intubation, manifesting as airway stenosis that may mimic bilateral vocal cord paralysis. It presents a variety of features that mandate specific surgical interventions. OBJECTIVES: To summarize our experience with PSG and its working diagnosis. METHODS: We conducted a retrospective review of a cohort of adult patients with PGS operated at the Sheba Medical Center between 1994 and 2006. RESULTS: Ten patients were diagnosed with PGS, 6 of whom also had stenosis at other sites of the larynx and trachea. Since 2000, all patients underwent laryngeal electromyographic studies and direct laryngoscopy prior to surgery. Surgical interventions included endoscopic laser procedures (in 2 patients), laryngofissure and scar incision (in 1), laryngofissure with buccal mucosa grafting (in 3) or with costal cartilage grafting (in 1) and laryngofissure with posterior cricoid split and stenting (in 1); one patient was not suitable for surgery. Postoperative follow-up included periodic fiberoptic endoscopies. Voice analysis was evaluated by the GRBAS grading. Seven patients were successfully decannulated within one to three procedures. Voice quality was defined as good in 7 patients, serviceable in 2 and aphonic in 1. CONCLUSIONS: Posterior glottic stenosis may be isolated or part of complex laryngotracheal pathologies. Electromyographic studies and direct laryngoscopy must be included in the diagnostic workup. Costal cartilage or buccal mucosa grafts are reliable, safe and successful with respect to graft incorporation and subglottic remodeling.

[Recurrent pleomorphic adenomas of the parotid gland--treatment and outcome].

Epithelial tumors of the parotid gland comprise 3% of head and neck tumors, and 70%-80% of those are benign. Pleomorphic adenoma is the most common tumor of the parotid gland. Recurrence rate of pleomorphic adenomas (RPAs) following superficial parotidectomy was reported to be as high as 4%, sometimes associated with inadequate surgical treatment of the primary tumor. These tumors have a very slow growth rate, and a ten-year follow-up period is mandatory. RPAs are usually located in the superficial lobe (75%) and are often multinodular. Treatment of RPAs is challenging due to a high risk of facial nerve paresis (7%-50%) and of re-recurrence. Occasionally, post-operative radiotherapy is indicated, but this treatment must be balanced with potential long term risks of secondary malignancy. Medical records of 16 patients with first recurrence and 4 patients with more than one recurrence who were treated in our institution during the past 5 years were reviewed. Five patients were treated by post-operative radiotherapy. Residual or recurrence rate following a second procedure was 15%. Two patients (10%) had permanent paresis of a single branch of the facial nerve. Seventeen out of 20 patients (85%) treated were disease-free after a follow-up period of 5 years. In conclusion, surgical treatment of RPAs is a complex procedure which should be managed by a trained surgical team and can be performed with success and minimal morbidity.

Nasal vestibulitis: etiology, risk factors, and clinical characteristics: A retrospective study of 118 cases.

BACKGROUND: Nasal vestibulitis (NV) is a common infection; however, scant data is available in the literature as it pertains to NV. We aim to describe the clinical characteristics of NV in respect to its potential complications. METHODS: A retrospective chart review of 118 NV cases admitted to a tertiary medical center between 2008 and 2015. RESULTS: Identified risk factors for NV included nasal hair plucking (n=15, 14.41%), nose blowing (n=10, 9.32%), nose picking (n=9, 8.47%) and nose piercing (n=5, 3.39%). Twelve patients (10.17%) were diabetic, and 3 patients were immunosuppressed. Mid-facial cellulitis was observed in the majority of patients (78.81%), and abscess of the nasal vestibule was observed in almost half (48.30%). Cultures were taken from 33.33% of patients demonstrated MSSA as the most common isolate (81.25%). No complications were observed. CONCLUSION: Even in complicated cases of NV requiring admission, the risk of major complications is extremely low.

Olfactory function in oncologic hospice patients.

INTRODUCTION: Normal sense of smell is important for well being. Although cancer is reported to be associated with impaired olfactory function, very few studies have directly evaluated this effect. PATIENTS AND METHODS: We performed a quantitative analysis of olfactory status in 42 hospice patients in a hospital-based hospice facility. Olfaction was assessed using the "Sniffin' Sticks" (Burghart Medical Technology, Tinsdaler, Germany) kit. RESULTS: Twenty-five patients (60%) were found to be hyposmic. CONCLUSION: Study results indicate the high incidence of decreased olfactory function among hospice patients.

Cricotracheal resection for airway reconstruction: The Sheba Medical Center experience.

BACKGROUND: Intubation and tracheostomy are the most common causes of benign acquired airway stenosis. Management varies according to different conceptions and techniques. OBJECTIVES: To review our experience with cricotracheal resection and to assess related pitfalls and complications. METHODS: We examined the records of all patients who underwent CTR in a tertiary referral medical center during the period January 1995 to April 2005. RESULTS: The study included 61 patients (16 women and 45 men) aged 15-81 years. In 17 patients previous interventions had failed, mostly dilatation and T-tube insertion. Complete obstruction was noted in 19 patients and stenosis > 70% in 26. Concomitant lesions included impaired vocal cord mobility (n=8) and tracheo-esophageal fistula (n=5). Cricotracheal anastomosis was performed in 42 patients, thyrotracheal in 12 and tracheotracheal in 7. A staged procedure was planned for quadriplegic patients and for three others with bilateral impaired vocal cord mobility. Restenosis occurred in six patients who were immediately revised with T-tube stenting. Decanulation was eventually achieved in 57 patients (93.4%). Complications occurred in 25 patients, the most common being subcutaneous emphysema (n=5). One patient died of acute myocardial infarction on the 14th postoperative day. CONCLUSIONS: CTR is a relatively safe procedure with a high success rate in primary and revised procedures. A staged procedure should be planned in specific situations, namely, quadriplegics and patients with bilateral impaired vocal cord mobility.

Quality of Life after Salivary Gland Surgery.

Quality of life (QoL) has been recognized as an important endpoint in addition to disease-related and global survival. It is particularly important for patients with salivary gland neoplastic disease. For patients who are undergoing benign salivary gland tumor surgery, cosmetic and functional outcomes are extremely important, as these patients' psychological well-being and ability to function in society can be severely impacted. The following issues related to surgical treatment are discussed: incision, loss of local tissue sensation, development of Frey's syndrome, facial nerve function, and cosmesis. Improvements in the placement of the incision combined with additional minimally invasive procedures have improved QoL. The ultimate goal of benign parotid neoplastic surgery is complete tumor excision while avoiding cosmetic and functional damage, which includes preservation of the function of the facial nerve and its branches; this is the key to maintaining preoperative levels of QoL. There are many measures available to improve cosmesis that have minimal morbidity and that, when used, can provide significant improvements in patient outcomes. The treatment of malignant salivary gland neoplasms is primarily directed at treating the malignancy. When surgical treatment affects important neighboring structures, such as the lingual or hypoglossal nerves, as in submandibular/sublingual cancer, there is a tremendous effect on QoL if postoperative dysfunction of these structures results. Often, this treatment involves using ancillary surgical procedures, such as neck dissection, or nonsurgical treatment, such as radiation therapy. The effect of such multi-modality treatment on QoL is significant. The treatment of underlying salivary disease is often overshadowed by these adjunctive treatments.

Limited use of complementary and alternative medicine in Israeli head and neck cancer patients.

HYPOTHESIS/OBJECTIVE: The use of complementary or alternative medicine (CAM) is growing among cancer patients. A Medline search failed to reveal any dedicated report of CAM use specifically in patients with head and neck cancer (HNC). STUDY DESIGN: Use of CAM was evaluated in a cohort of treated HNC patients. METHODS: Patients treated for HNC were asked if they had used CAM since their diagnosis. Demographic data and data pertaining to mode of CAM, duration of treatment and effects were obtained. RESULTS: One hundred forty-three patients (mean age 61 years) were included. Only nine patients (6.3%) reported using disease related CAM. This included acupuncture (4), Reiki (2), naturopathy (2), hypnosis (1), shiatsu (1), chiropractic treatment (1), homeopathy (1), and selenium (1). CONCLUSION: Contrary to the reported use, few of our HNC patients used CAM. Although this could be related to good caregiver-patient relationship, further studies in comparable populations are warranted to evaluate if this is a local or a pervading finding in head and neck cancer patients.